Multi-portal surgical systems, cannulas, and related technologies

ABSTRACT

A multi-portal method for treating a subject&#39;s spine includes distracting adjacent vertebrae using a distraction instrument positioned at a first entrance along the subject to enlarge an intervertebral space between the adjacent vertebrae. An interbody fusion implant can be delivered into the enlarged intervertebral space. The interbody fusion implant can be positioned directly between vertebral bodies of the adjacent vertebrae while endoscopically viewing the interbody fusion implant using an endoscopic instrument. The patient&#39;s spine can be visualized using endoscopic techniques to view, for example, the spine, tissue, instruments, and implants before, during, and after implantation, or the like. The visualization can help a physician throughout the surgical procedure to improve patient outcome.

CROSS-REFERENCE TO RELATED APPLICATION

The present application is a continuation-in-part of U.S. patentapplication Ser. No. 16/565,403, filed Sep. 9, 2019, and entitled“MULTI-PORTAL SURGICAL SYSTEMS,” which is incorporated by reference inits entirety.

TECHNICAL FIELD

The present disclosure relates generally to medical systems and, moreparticularly, to systems, devices, and methods for performingmulti-portal surgical procedures.

BACKGROUND

Individuals often suffer from damaged or displaced spinal discs and/orvertebral bodies due to trauma, disease, degenerative defects, or wearover an extended period of time. One result of this displacement ordamage to a spinal disc or vertebral body may be chronic back pain. Acommon procedure for treating damage or disease of the spinal disc orvertebral body may involve partial or complete removal of anintervertebral disc. An implant (commonly referred to as an interbodyspacer) can be inserted into the cavity created where the intervertebraldisc was removed to help maintain height of the spine and/or restorestability to the spine. An interbody spacer may also provide a lordoticcorrection to the curvature of the spine. An example of an interbodyspacer that has been commonly used is a fixed dimension cage, whichtypically is packed with bone and/or bone-growth-inducing materials.Unfortunately, it may be difficult to implant the interbody spacer atthe intended implantation site between vertebral bodies. Additionally,conventional surgical techniques can cause a significant amount oftrauma at or near the implantation site, which can significantlyincrease recovery time and lead to patient discomfort. Accordingly,there is a need for improved surgical systems, visualization techniques,and/or related technologies.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a side view of a multi-portal surgical system in accordancewith an embodiment of the disclosure.

FIG. 2 is a schematic top plan view showing surgical approaches to alumbar spine for performing interbody fusion procedures.

FIG. 3 is an isometric view of the lumbar spine of FIG. 2 .

FIG. 4 is a side view of a tissue removal device positioned betweenadjacent vertebrae and a visualization device positioned to visualize aworking area in accordance with an embodiment of the disclosure.

FIG. 5 is a side view of a distraction instrument with a collapsedexpansion element positioned at an intervertebral space and avisualization device in accordance with an embodiment of the disclosure.

FIG. 6 is a side view of the distraction instrument with the inflatedexpansion element contacting endplates of vertebral bodies in accordancewith an embodiment of the disclosure.

FIG. 7 is a side view of a distraction instrument with an expansionelement in accordance with an embodiment of the disclosure.

FIG. 8 is a side view of an instrument positioned between two vertebraein accordance with an embodiment of the disclosure.

FIGS. 9A, 9B, and 9C are views from an anterior direction of a subject'sspine with an interbody spacer positioned between vertebrae inaccordance with an embodiment of the disclosure.

FIG. 10A is a side view of the interbody spacer in a collapsedconfiguration.

FIG. 10B is a side view of the interbody spacer in an expandedconfiguration.

FIG. 11 is a flow diagram illustrating a method for performing a spinesurgery in accordance with an embodiment of the disclosure.

FIG. 12 illustrates a system for providing assistance prior to, during,or after surgery according to an embodiment of the disclosure.

FIG. 13 is a plan view of a surgical kit in accordance with anembodiment of the disclosure.

FIG. 14 is a perspective view of a tissue-mapping cannula in accordancewith an embodiment of the disclosure.

FIG. 14A is a perspective view of a distal end of the cannula of FIG. 14with lumens and tissue-mapping probes in accordance with an embodimentof the disclosure.

FIG. 14B is a perspective view of a proximal end of the cannula of FIG.14 .

FIG. 14C is a longitudinal cross-sectional view of the cannula of FIG.14 .

FIG. 15 is an end view of a distal end of a cannula with a plurality oflumens and an array of tissue-mapping probes in accordance with anembodiment of the disclosure.

FIG. 16 is a side view of a cannula with a protruding tissue-mappingprobe according to an embodiment of the disclosure.

FIG. 17 is a side view of a surgical system with cannulas that circulatesurgical irrigation fluid and map tissue in accordance with anembodiment of the disclosure.

FIG. 18 is a side view of a cannula with a deployable expander carryingtissue-mapping probes in accordance with an embodiment of thedisclosure.

FIG. 19 is an enlarged top view of the cannula of FIG. 18 with theexpander in a deployed configuration.

FIG. 20 is a flow diagram illustrating a method for performingmulti-portal spine surgery with circulated irrigation flow and/ortissue-mapping in accordance with an embodiment of the disclosure.

DETAILED DESCRIPTION

The following disclosure describes various embodiments of medicalsystems and devices and associated methods of use. At least someembodiments of a surgical system provide visualization capability. Aseries of instruments can be delivered via portal sites and used toalter tissue (e.g., shape, crush, separate, cut, debulk, break,fracture, or remove tissue), prepare an implantation site, implant adevice, combinations thereof, or the like. Instrument visualization canhelp a physician prevent or limit injury or damage to non-targetedorgans and tissues. In endoscopic-assisted surgeries, devices can beprecisely implanted using minimally-invasive techniques to improveoutcomes and reduce recovery times. Certain details are set forth in thefollowing description and in FIGS. 1-20 to provide a thoroughunderstanding of such embodiments of the disclosure. Other detailsdescribing well-known structures and systems often associated with, forexample, surgical procedures are not set forth in the followingdescription to avoid unnecessarily obscuring the description of variousembodiments of the disclosure.

A. Overview

At least some embodiments are directed to multi-portal surgical systems.The surgical systems can be used to treat patients with damaged ordisplaced spinal discs and/or vertebral bodies. The surgical systems canbe used to implant a fixed or expandable interbody device to space apartvertebral bodies, restore stability of the spine, provide lordoticcorrection, combinations thereof, or the like. In spinal fusionprocedures, interbody devices can be used alone or in combination withbone, bone-growth-inducing materials, fixation devices (e.g., pediclescrew systems, fixation rods, etc.), or the like. The patient's spinecan be visualized using endoscopic techniques to view, for example, thespine (e.g., vertebral spacing, vertebral alignment, etc.), tissue(e.g., damaged or displaced sections of intervertebral cartilage disc,tissue contributing to nerve compression, etc.), instruments andimplants before, during, and after implantation, or the like. Thevisualization can help a physician throughout the surgical procedure toimprove patient outcome.

The surgical system can provide access to the surgical site. Theimplantation site can be prepared by performing a discectomy, interbodypreparation procedure, or the like. One or more devices (e.g., implants,fusion devices, etc.) can be delivered and placed within the patient. Insome embodiments, decompression procedures can be performed to minimizeor reduce pressure applied to nerve tissue and can include removingtissue contributing to stenosis, tissue pushing against nerve tissue,bulging sections of intervertebral cartilage disc, or the like. Forexample, decompression procedures can be performed to enlarge anepidural space to reduce spinal cord compression.

One surgical method includes positioning a distraction instrumentbetween adjacent vertebrae at a first portal site along the patient toenlarge an intervertebral space. A tissue removal device can be used toclear and prepare the enlarged intervertebral space for implantation. Aninterbody fusion implant can be delivered into the enlargedintervertebral space. The expanding interbody fusion implant isendoscopically viewed using an endoscopic instrument, which ispositioned at a second entrance along the patient. Endoscopic viewingcan be used to evaluate whether the expanded interbody fusion implant isat the desired location, assist in delivering bone graft material, orother steps that promote bone healing and facilitate spinal fusion.Other visualization techniques can be used in combination with theendoscopic viewing. For example, fluoroscopy can be used in combinationwith endoscopic viewing.

In some embodiments, a multi-portal, endoscopy-assisted method fortreating a subject includes performing at least a portion of a surgicalprocedure by using a first portal site. At least a portion of thesurgical procedure uses an endoscope positioned via a second portal sitespaced apart from the first portal site. The spacing can be selectedbased on location and accessibility of the treatment site(s), whetheralong the spine or at another location.

In some embodiments, a multi-portal method for treating a subject'sspine includes distracting adjacent vertebrae using a distractioninstrument positioned at a first entrance along the subject to enlargean intervertebral space between the adjacent vertebrae. An interbodyfusion implant is delivered into the enlarged intervertebral space. Theinterbody fusion implant is positioned directly between vertebral bodiesof the adjacent vertebrae while being endoscopically viewed using anendoscopic instrument. The endoscopic instrument can be positioned at asecond entrance along the subject. The positions of the first and secondentrances can be selected based on the accessibility of the implantationsite.

In yet further embodiments, a multi-portal method for treating a spineof a subject includes positioning a first cannula at a first portalalong the subject. A first vertebral body and a second vertebral bodyare distracted using one or more distraction instruments, which canextend through the first cannula. The interbody fusion implant can bemoved, via the first cannula, toward an intervertebral implantation sitebetween the distracted first and second vertebral bodies. At least aportion of the intervertebral implantation site and at least a portionof the interbody fusion implant can be visualized using an endoscopicinstrument positioned at a second portal along the subject.

In some embodiments, a spinal implant delivery instrument includes anelongated body configured to be positioned in a cannula and a distractorassembly. The distractor assembly can be coupled to the elongated bodyand movable from a delivery state to an expanded state to distract firstand second vertebral bodies. In certain embodiments, the distractorassembly in the delivery state is configured for insertion into anintervertebral space between the first and second vertebral bodies and,in the expanded state, is configured to hold apart the distracted firstand second vertebral bodies while an interbody fusion implant isdelivered into the intervertebral space.

In further embodiments, a spinal implant delivery instrument includes anelongated body configured to be positioned in a cannula and a distractorassembly coupled to the elongated body. The distractor assembly ismovable from a delivery state to an expanded state to distract first andsecond vertebral bodies. The distractor assembly in the delivery stateis configured for insertion into an intervertebral space and, in theexpanded state, is configured to hold apart the distracted first andsecond vertebral bodies while an interbody fusion implant is delivered.The interbody fusion implant can be delivered from the distractorassembly and into the intervertebral space. In some embodiments, adriver is detachably couplable to a rotatable connection interface ofthe interbody fusion implant. The driver can move axially to move theinterbody fusion implant directly between the first and second vertebralbodies. The driver is configured to expand the interbody fusion implantfrom a collapsed configuration to a deployed configuration. Thedistractor assembly can include a jaw operable to define a delivery gapthrough which the interbody fusion implant can be delivered.

In some embodiments, a multi-portal method for treating a subject'sspine includes inserting multiple cannulas into a subject. The cannulascan be used to identify tissue to, for example, facilitate placement ofthe cannulas/instruments and/or identify tissue (e.g., targeted tissue,non-targeted tissue, etc.), or the like. The cannulas can be used tocirculate (e.g., continuously or intermittently) irrigation fluid (e.g.,saline, water, etc.) through and around the surgical site.Tissue-mapping and surgical site irrigation can be performedconcurrently or sequentially. In some embodiments, fresh irrigationfluid can be delivered by an irrigation system through a first cannula.The irrigation system can have one or more pumps that generate desiredback pressure. To remove the irrigation fluid, another cannula can drawan optional vacuum to suck the irrigation fluid and unwanted material(e.g., blood, bone dust, loose tissue, etc.) out of the subject.Additionally, the pressurized irrigation fluid in the subject can helppromote hemostasis. The cannulas can be used to generate desired flowsof irrigation fluid.

Irrigation fluid (e.g., flows of irrigation fluid into and/or out of thesubject) can be monitored to, for example, facilitate visualization,provide feedback to a clinician, or the like. In some embodiments,irrigation fluid can be circulated periodically based on endoscopicvisibility. If the system detects an excess amount of bone dust, forexample, the system can automatically circulate irrigation fluid throughthe surgical site to remove bone dust. In some embodiments, a cliniciancan control, via a control pedal, hand controls, etc., when irrigationfluid is circulated. Advantageously, the cannulas can have fluid lumensspaced apart from working lumens such that the irrigation fluid flowrates can be increased or decreased without interfering with instrumentslocated in the working lumens. This allows for independent control ofinstruments and irrigation.

The cannulas can include, without limitation, sensors (e.g., flowsensors), flow diffusers, flow spreaders, valves (e.g., one-way valves),fittings (e.g., fittings for connecting to hoses), connectors, and otherfluidic components. For example, proximal ends of cannulas can have oneor more fittings for connecting to fluid lines of an irrigation system.Distal ends of cannulas can include nozzles for directing flows in adesired direction. The configuration of the cannulas can be selectedbased on the desired circulation. For example, to reduce or minimizetrauma to tissue positioned immediately distal to the cannula, thecannula can have outlets or nozzles configured to direct fluid laterallyaway from non-targeted tissue. The cannula can direct a stream ofirrigation fluid toward the vacuum cannula. Cannulas can also have oneor more expanders, including mechanical expanders, pneumatic expanders,or the like.

In some embodiments, information obtained using cannulas can be used toguide instruments, evaluate the surgical procedure, confirm whether aprocedure has been completed, or the like. In embodiments withtissue-identifying probes, the cannulas can be used to identify one ormore types of tissue. Nerve-detecting probes can be used to identifynerve tissue, for example. This allows a surgeon to perform procedureswhile minimizing or limiting the impact to nerve tissue. In someautomated detection embodiments, a system can automatically notify auser that the cannula is contacting or adjacent to non-targeted tissue.The surgeon can keep the cannula at a safe location. In some procedures,the cannula is used to map a pathway to a surgical site, a surgical siteitself, or other desired location.

The surgeon can manually rotate a cannula to map tissue around andproximate to the distal end of the cannula. In other embodiments, thecannula can have a distal end that automatically rotates for mapping anarea. Such a cannula can include one or more motors, actuators, or thelike.

In yet other embodiments, a cannula includes an elongated body and aplurality of lumens extending through the elongated body. One of thelumens can be a working lumen configured to allow a surgical instrumentto pass therethrough. Another one of the lumens can be a fluid lumenconfigured to provide a flow of surgical irrigation fluid to/from thesurgical site. In some embodiments, the cannula can have additionalfluid lumen configured to provide another flow of irrigation fluid.

In multi-portal surgical techniques, two cannulas can be used tocirculate irrigation fluid. In some embodiments, a fluid lumen of afirst cannula can be connected to an irrigation fluid supply system.Irrigation fluid can flow through a fluid lumen and exit a distal end ofa first cannula. The irrigation can flow along the surgical site. Theirrigation fluid can be drawn from the surgical site through a fluidlumen of a second cannula. In some embodiments, the first and/or secondcannulas can have two or more fluid lumens. Additional lumens can beconnected to either the fluid supply system or the fluid return system.In this way, any of the cannulas can be configured to supply or returnirrigation fluid. In further embodiments, cannulas can be configured toboth supply and return irrigation fluid.

The irrigation fluid supply system can include one or more fluid supplyreservoirs, pumps, flow monitors, pressure monitoring devices, flowcontrol mechanisms, or the like. Similarly, the fluid return system caninclude one or more pumps, pressure monitoring devices, flow controlmechanisms, return fluid containers, or the like. The supply and returnsystems can be components of an irrigation fluid control system. Theirrigation fluid control system can provide monitoring, such as flowmonitoring, pressure monitoring, etc. In some embodiments, the controlsystem can selectively supply and return fluid through any one of theconnected fluid lumens according to the needs of the surgical procedure.

Additionally, cannulas can include one or more detectors, such astissue-mapping probes. The detectors can be configured to output and/orreceive energy to acquire information, identify tissue (e.g., tissue ator near the treatment site), and/or monitor treatment. In someembodiments, the detectors are neuromonitoring electrodes configured toidentify nerves using, for example, electromyography techniques. Mappingthe location of nerves can be useful to guide the position of thecannula, instruments, or other devices to reduce or avoid nerve tissueinjury. The detectors can be connected to a tissue-mapping systemprogrammed to determine locations of tissue. The tissue-mapping systemcan provide feedback about the location of tissue, including, forexample, an audible tone indicating proximity to a nerve or other tissue(e.g., targeted tissue, non-targeted tissue, etc.). In otherembodiments, the tissue-mapping system can provide a visual indicationof the location of tissue. The visual indication can be, for example,image(s), identifiers of tissue locations overlaid on image data (e.g.,still image(s), video, etc.) provided by a visualization instrument,such as an endoscope, fiber optic viewing system, or the like.

In further embodiments, a cannula can include a deployable expander. Theexpander can be configured to enlarge spaces or working volumes, therebyaiding visibility and/or facilitating the flow of irrigation fluid to orfrom the cannula. The expander can have a delivery configuration tominimize its profile during insertion into the subject. The expander canbe coupled to or part of the distal end of the cannula such that thebody of the expander contacts the cannula body. In other embodiments,the expander is coupled to the cannula by a connector mechanism andextendably engaged with the cannula body to extend the expander adistance away from the cannula body, for example, prior to and/or duringdeployment. In yet other embodiments, the expander is a separate deviceconfigured to be delivered through one of the working lumens of thecannula.

The expander can include one or more tissue-mapping probes. These probescan be in place of or in addition to tissue-mapping probes located on acannula body. The probes can be used to aid the positioning of thecannula, the deployment and/or positioning of the expander, theinsertion and use of a surgical instrument, and/or the evaluation of theprocedure (e.g., to determine whether a nerve has been damaged orsevered).

Embodiments of the present disclosure will be described more fullyhereinafter with reference to the accompanying drawings in which likenumerals represent like elements throughout the several figures, and inwhich example embodiments are shown. Embodiments of the claims may,however, be embodied in many different forms and should not be construedas limited to the embodiments set forth herein. The examples set forthherein are non-limiting examples and are merely examples among otherpossible examples.

B. Multi-Portal Surgical Systems

FIG. 1 is a side view of a spinal surgical system 100 (“system 100”)positioned along a human subject's spine in accordance with anembodiment of the disclosure. The system 100 can include an instrumentassembly 130 and a visualization assembly 160. The instrument assembly130 can be used to perform at least a portion of a surgical procedurewhile the visualization assembly 160 provides visualization. Theinstrument assembly 130 can include an instrument 110 and a cannula 120.Ports can be used to facilitate insertion of the instrument assembly 130and/or visualization assembly 160. For example, the visualizationassembly 160 can be positioned in an endoscope port, and the instrumentassembly 130 can be positioned in an instrument port.

A series of instruments can be delivered through the cannula 120 toperform a surgical procedure. In some procedures, the instrument 110 canbe used to prepare an implantation site by, for example, moving organsor tissue (e.g., moving nerve tissue), removing tissue (e.g., removingthe intervertebral disc 171, removing tissue contributing to stenosis,etc.), preparing vertebral bodies (e.g., roughening or shaping vertebralendplates), or the like. The instrument 110 can be removed and adistraction instrument can be delivered through the cannula 120. Thedistraction instrument can distract adjacent vertebrae 170, 172, therebyenlarging the intervertebral space. An interbody fusion implant can bedelivered through the cannula 120 and into the enlarged intervertebralspace. In expandable embodiments, the interbody spacer or fusion implantcan be expanded to contact vertebral endplates. During the procedure,the visualization assembly 160 can provide endoscopic viewing ofdelivery paths, organs, tissue (e.g., nerve tissue) implantation sites,interbody fusion devices (e.g., before, during, and/or after delivery),instrument(s), and other areas or features of interest. The position ofthe portal sites for the instrument assembly 130 and the visualizationassembly 160 can be selected based on the procedure to be performed andoptical characteristics (e.g., field of view, zoom capability, etc.) ofthe visualization assembly 160, as discussed in connection with FIG. 4 .

With continued reference to FIG. 1 , the visualization assembly 160 caninclude a visualization device 140 and a cannula 150. The cannula 150can help a physician when switching between visualization devices. Insome embodiments, the visualization assembly 160 can be used without thecannula 150. For example, the visualization device 140 in the form of alow-profile fiber optic endoscope positioned directly through anincision, an endoscopic port, or the like. The visualization device 140can include one or more endoscopes having, without limitation, fiberoptics (e.g., optical fibers), lenses, imaging devices, working lumens,light sources, controls, or the like for direct viewing or viewing via adisplay 162. In some embodiments, the visualization device 140 caninclude a lumen through which fluid flows to irrigate the surgical site.For example, saline, or another suitable liquid, can be pumped throughthe visualization device 140 to remove tissue (e.g., loose tissue, bonedust, etc.) or other material impairing visualization. The visualizationdevice 140 can illuminate the body cavity and enable high-resolutionvideo visualization. A light source (e.g., a laser, light-emittingdiode, etc.) located near or at the proximal end of the fiber optics canbe used to transmit light to the distal end and provide illuminatinglight. This enables a surgeon to safely navigate into the subject's bodyand to illuminate specific body anatomy to view vertebral spacing,vertebral structures, nerves, bony buildup (e.g., buildup that could beirritating and pressing against nerves contributing to nervecompression), etc. In some embodiments, visualization optics for visionand illumination are included within the distal tip of the visualizationdevice 140. The configuration and functionality of the visualizationdevice 140 can be selected based on the desired field of view, viewingresolution, pan/zoom functionality, or the like.

FIG. 2 is a schematic top plan view along the lumbar spine of a humanand illustrates example approaches for performing interbody fusionprocedures suitable for the system 100 of FIG. 1 . FIG. 3 is anisometric view of the lumbar spine of FIG. 2 . Referring to FIGS. 2 and3 , surgical instruments can be delivered via different paths, includingan anterior lumbar interbody fusion (ALIF) path 210, an oblique lumbarinterbody fusion (OLIF) path 220, a lateral or extreme lateral lumbarinterbody fusion (LLIF or XLIF) path 230, a transforaminal lumbarinterbody fusion (TLIF) path 240, and a posterior lumbar interbodyfusion (PLIF) path 250. Example TLIF and PLIF procedures are discussedin connection with FIGS. 4-6 .

With continued reference to FIGS. 2 and 3 , the number and configurationof interbody fusion devices can be selected based on the fusionprocedure to be performed. In one example TLIF procedure, thetransforaminal path 240 may be employed to implant a single smallexpandable or non-expandable interbody spacer at the intervertebralspace. In one example PLIF procedure, two interbody spacers can bedelivered along the posterior path 250 and implanted at theintervertebral space. The two interbody spacers can cooperate to keepthe vertebral bodies at the desired spacing and may be larger than theTLIF spacer. Additionally, multiple interbody spacers can providelordotic correction by providing support at different heights. In oneexample LLIF procedure, a single relatively large interbody spacer canbe delivered along the lateral path 230 and implanted to provideasymmetrical support. In one example ALIF procedure, an asymmetricinterbody spacer can be delivered along the anterior path 210 to providesupport consistent with lordosis at that portion of the spine. Lateralapproaches, transforaminal approaches, and anterior approaches can beused to access the cervical spine, thoracic spine, etc. The number ofinstruments, configurations of instruments, implants, and surgicaltechniques can be selected based on the condition to be treated.

FIG. 4 is a detailed side view of the instrument assembly 130 positionedto perform a TLIF or PLIF procedure in accordance with embodiments ofthe disclosure. The instrument assembly 130 can extend through a port472, and the visualization assembly 160 can extend through a port 474.The illustrated instrument assembly 130 can extend through the subject'sskin 460, through subcutaneous tissue 462, and adjacent to or throughsupraspinal ligament 464. The visualization assembly 160 has a field ofview 213 suitable for viewing the spinal column and can be positionedusing, for example, a transforaminal approach, a posterior approach, ora lateral approach. The illustrated visualization assembly 160 ispositioned to enable viewing an intervertebral disc 430 and a tissueremoval tip 470 of the instrument 110, which is illustrated betweenspinous processes 450, 454 of vertebrae 440, 444, respectively.Fluoroscopy, MR imaging, CT imaging, direct visualization, or othervisualization techniques can be used in addition to or in lieu of theendoscopic viewing.

The tissue removal tip 470 can be advanced in the anterior direction toremove the intervertebral disc 430, or other unwanted tissue, including,without limitation, tissue bulging from disc 430 (or other discs), bone(e.g., lamina, lateral recesses, facets including the inferior facets,etc.), bone spurs (e.g., bone spurs associated with osteoarthritis),tissue of thickened ligaments, spinal tumors, displaced tissue (e.g.,tissue displaced by a spinal injury), or tissue that may cause orcontribute to spinal nerve compression. The instrument 110, as well asother instruments (e.g., rongeurs, debulkers, scrapers, reamers,dilators, etc.), can be used to perform one or more dilation procedures,decompression procedures, discectomies, microdiscectomies, laminotomies,or combinations thereof. In procedures for treating stenosis, theinstrument 110 can be used to remove tissue associated with centralcanal stenosis, lateral recess stenosis, and/or other types of stenosis.In some decompression procedures, the instrument 110 can be a tissueremoval device used to, for example, remove bone, separate theligamentum flavum from one or both vertebrae 440, 444, cut or debulk theligamentum flavum, remove loose tissue, and remove at least a portion ofthe intervertebral disc 430. Each stage can be performed with adifferent instrument. Instruments can be selected to treat, withoutlimitation, spinal nerve compression (e.g., spinal cord compression,spinal nerve root compression, or the like), spinal disc herniation,osteoporosis, stenosis, or other diseases or conditions.

The instrument 110 and the visualization device 140 can be positionedalong different paths. For example, the instrument 110 can be positionedalong a posterior path, whereas the visualization device 140 can bepositioned along a transforaminal or oblique path. The ports 472, 474are positioned at different superior-inferior positions, and the port472 is positioned directly posterior to the treatment site such that alongitudinal axis of the tissue removal device 110 lies in a plane thatis generally parallel to a transverse plane of the subject. Thevisualization device 140 can be, without limitation, an endoscopicinstrument that includes fiber optics 480 suitable to image theligamentum flavum, spinal cord, nerves branching from spinal cord,ligament, vertebrae 440, 444, intervertebral disc 430, or any otherfeatures or anatomical structures of interest while the instrument 110removes tissue (e.g., bone from the vertebrae 440, 444 or tissueintervertebral disc 430).

FIG. 5 is a side view of a distraction instrument with a collapsedexpansion element positioned between two vertebrae after anintervertebral disc has been removed in accordance with an embodiment ofthe disclosure. A distraction instrument 510 is positioned in thecannula 120 and has positioners or stops 530, 534 and an expander ordistractor head 560 (“expander 560”), illustrated in a partiallyexpanded state, configured to push apart the adjacent vertebrae 440,444. Expansion of the expander 560 and the positioners 530, 534 can beviewed endoscopically with the visualization device 140.

The positioners 530, 534 are configured to help position the expander560 insertable into an intervertebral space 570. For example, thepositioner 530 can contact an inferior vertebral notch 550 of thevertebral body 441, and the positioner 534 can contact a superiorvertebral notch 554 of the vertebral body 445. An elongate member 540can be extended or contracted to position the expander 560 at a desiredlocation, while the positioners 530, 534 can remain relativelystationary relative to the vertebral bodies 441, 445. Throughout thisprocess, the visualization device 140 can be used to view thepositioners 530, 534, the elongate member 540, and/or the expander 560.A physician can confirm the condition of expander 560 relative toanatomical features prior, during, and after expansion. This ensuresthat the expander 560 contacts desired regions of the spinal column. Theexpander 560 can be deployed to push against endplates of the adjacentvertebrae 440, 444, thereby enlarging the intervertebral space 570.

The positioners 530, 534 can include spikes, protrusions, or othermovement-inhibiting elements. In some embodiments, anchors orprotrusions can be connected directly to the elongate member 540 and canbe deployed to engage the endplates. The configuration, number, andposition of the positioners can be selected based on the desiredpositioning relative to the spinal column.

The elongate member 540 is connected to the expander 560 and can be arod with one or more lumens through which fluid flows. Fluid (e.g.,saline, gas, or another suitable fluid) can be pumped through theelongate member 540 to inflate the expander 560. For fluoroscopy, thefluid can include a contrast media. The expander 560 can include,without limitation, one or more inflatable members, balloons, mechanicalexpanders, wedging devices, or the like. Arrows indicate one of the manypossible directions of expansion, and the direction of expansion of theexpander 560 is not limited to bidirectional expansion.

The distraction instrument 510 can also deliver an interbody fusionimplant and serve as a driver instrument. The distraction instrument 510can have a shaft connectable to the interbody fusion implant. The shaftcan be rotated to deploy the interbody fusion implant. U.S. Pat. Nos.8,632,594, 9,308,099, 10,105,238 and 10,201,431, which are herebyincorporated by reference and made a part of this application, disclosedriver components that can be incorporated into the distractioninstrument 510.

FIG. 6 is a side view of the distraction instrument 510 with an inflatedexpansion element 560 holding apart the vertebral bodies 441, 445. Thelevel of expansion of expander 560 can be increased or decreased toincrease or decrease, respectively, the pressure applied to theendplates. The expander 560 can include one or more roughened surfaces,spikes, protrusions, or other features capable of roughening, abrading,scraping, or otherwise affecting tissue. In some embodiments, theexpander 560 has a plurality of protruding spikes that can be used toroughen the opposing vertebral endplate surfaces to help limit orsubstantially prevent migration of an implanted device. The expander 560can be collapsed and removed. Another expander can be inserted into thealready-expanded intervertebral space 570 to further distract thevertebrae 440, 444. In this manner, the vertebrae can be sequentiallydistracted in a controlled manner until a desired amount of separationis achieved.

The expander 560 can hold apart the distracted second vertebral bodies441, 445 while an interbody fusion implant is delivered through thedistraction instrument 510 and into the intervertebral space 570. Theinterbody fusion implant can be positioned adjacent to the deployedexpander 560, which can be removed after, for example, deploying theinterbody fusion implant.

The configuration of the instruments can be selected based, at least inpart, on the distance from the portal sites to the treatment site. Thesurgical procedure can be selected based on the steps to be performed.For example, TLIF and PLIF surgery can include a decompression procedurein which tissue along the posterior region of the spine is removed incontrast to an ALIF procedure in which no such decompression procedureis performed. The systems and techniques discussed in connection withFIGS. 4-6 can be modified to perform other types of procedures,including non-spine procedures.

FIG. 7 is a side view of a distraction instrument 700 with an expansionelement in accordance with an embodiment of the disclosure. Theinstrument 700 can include control elements 710, 712, an elongated body720, positioners 730, 740, and an expander assembly 758. The controlelements 710, 712 can be operated to deploy the positioners 730, 740and/or expander assembly 758. For example, a user can manually rotatethe control elements 710, 712 to independently deploy the respectivepositioners 730, 740. For example, the control element 710 can be usedto rotate the positioners 730, 740 away from undeployed positions 732,742 (illustrated in dashed line) and a longitudinal axis 743 of theinstrument 700 and toward the illustrated outwardly deployed positions.

The distraction instrument 700 can be used in a similar manner asdescribed in connection with FIGS. 5 and 6 . For example, the deployedpositioners 730, 740 can rest against adjacent vertebrae. The expanderassembly 758 has an expander or distractor head 760 (“expander 760”)positionable at a desired location suitable for distracting thevertebrae. The expander assembly 758 can include an elongated body 750fluidically connected to a fluid line 751. The expander 760 can bemounted to the distal end of the elongated body 750 such that fluid canbe pumped through the fluid line 751, through the elongated body 750,and into the expander 760.

FIG. 8 is a side view of an instrument 800 positioned to distractadjacent vertebrae in accordance with an embodiment of the disclosure. Adescription of the instruments discussed in connection with FIGS. 4-7applies equally to the instrument 800 unless indicated otherwise.

The instrument 800 can include an access device or cannula 810 and adistraction assembly 828. The cannula 810 can serve as an access devicethrough which the distraction assembly 828 can be delivered. Thedistraction assembly 828 can include positioners 830, 834 configured foratraumatic contact with the spinal column. The positioners 830, 834 canbe inflatable members (e.g., inflatable balloons), mechanically expandedmembers, or other types of elements. The positioners 830, 834 can beconfigured to contact vertebral bodies, transverse processes, spinousprocesses, or the like. The distraction assembly 828 can further includean expandable assembly 848 with an expander 850 and an elongated body852. The illustrated expander 850 is in a collapsed, deflatedconfiguration or state. The expander 850 can be expanded/inflated in amanner similar to the expander 560 discussed in connection with FIGS. 5and 6 . A visualization device can be used to view the expander 850,positioners 830, 834, or other features of the instrument before,during, and/or after the distraction process. In some embodiments, thedistraction assembly 828 can function as a jaw in which the positioners830, 834 can be used to grip or define a delivery gap. Additionally oralternatively, the positioners 830, 834 can be inserted into spaces(e.g., cavities) and then moved apart to expand the spaces.

FIGS. 9A-9C are anterior views from an anterior direction of a subjectof an interbody spacer 910 between two vertebrae in accordance with anembodiment of the disclosure. In FIG. 9B, the interbody spacer 910 is ina laterally expanded configuration. In FIG. 9C, the interbody spacer 910is in a laterally and vertically expanded configuration. In general, theinterbody spacer 910, in a collapsed configuration, can be deliveredinto an intervertebral space. After endoscopically viewing the positionof the interbody fusion implant, the implant can be moved from thecollapsed configuration (FIGS. 9A and 10A) to an expanded configuration(FIGS. 9C and 10B). The expansion (e.g., lateral expansion, verticalexpansion, combinations thereof, etc.) can be viewed using theendoscopic instrument. The interbody spacer 910 can be, withoutlimitation, an implant, an interbody fusion implant, or the like.Details of the operation of the interbody spacer 910 are discussed indetail below.

Referring now to FIG. 9A, the intervertebral disc has been removed fromthe intervertebral space 907. The interbody spacer 910 can be deliveredthrough a cannula, such as the cannula 120 of FIGS. 1-7 or the cannula810 of FIG. 8 , to position the collapsed interbody spacer 910 directlybetween endplates 912, 914 of the vertebrae 440, 444, respectively. Theposition of the collapsed interbody spacer 910 can be confirmed viaendoscope viewing. If the interbody spacer 910 is at an undesiredposition, the interbody spacer 910 can be moved to another position.Once again, endoscopic viewing can be used to confirm the final positionof the interbody spacer 910.

FIG. 9B shows the interbody spacer 910 after it has been laterallyexpanded under endoscopic viewing. Advantageously, if the expansionprocess causes unwanted displacement of the interbody spacer 910, theuser can reposition the interbody spacer 910.

FIG. 9C shows the interbody spacer 910 after it has been verticallyexpanded against endplates 912, 914 of the vertebrae 440, 444,respectively. After full expansion, the interbody spacer 910 can belocked to prevent collapse. Optional material can be delivered to theintervertebral space 907 to promote or facilitate fusion. For example,material can be delivered into the intervertebral space 907 via adelivery instrument 920 (FIG. 10A) connected to the interbody spacer910. The material can be bone, bone-growth-inducing materials, cement,or other suitable material. The bone-growth-inducing materials can beconfigured to promote bony arthrodesis. In some procedures, the materialis delivered through the passageway of the delivery or driverinstrument. In other procedures, the material can be delivered via aseparate instrument. In some procedures, multiple interbody spacers areimplanted at the intervertebral space 907. Details of deliveryinstruments are discussed in connection with FIGS. 10A and 10B.

Referring to FIG. 10A, the interbody spacer 910 and delivery instrument920 can be delivered through a port 922, with or without the use of acannula 930. The instrument 920 can include a handle assembly 931, anelongated body 932, and a connecter 934. The handle assembly 931 caninclude a grip 950 and one or more control elements 940 operable tocontrol operation of the interbody spacer 910 and control decouplingfrom the interbody spacer 910. In some embodiments, the control elements940 can include one or more dials, levers, triggers, or other movableelements. The elongated body 932 is connected to the handle 950 andextends to the connecter 934. The elongated body 932 can serve as adriver instrument and can include one or more rods, shafts, or otherelements used to operate the interbody spacer 910. In some embodiments,a driver instrument is inserted through the delivery instrument 920 andinto engagement with the interbody spacer 910. The driver instrument canbe rotated to gradually and controllably deploy the interbody spacer910. The features, configuration, and functionality of the connector 934can be selected based on the configuration of the interbody spacer 910.

FIG. 10B is a side view of the expanded interbody spacer 910 after thedelivery instrument 920 has been separated from a connection feature orconnection interface 916 (“connection feature 916”) of the interbodyspacer 910. The expanded interbody spacer 910 can be locked in theexpanded configuration. To reposition the interbody spacer 910, thedelivery instrument 920 can be reconnected to the interbody spacer 910and operated to unlock and collapse the interbody spacer 910. Thedelivery instrument 920 can be used to move the collapsed interbodyspacer 910.

The delivery instrument 920 can include one or more distal connectionelements or features for detachably coupling to the interbody spacers.The connection elements can be a polygonal connection (e.g., a hexagonalprotrusion) received by a complementary polygonal recess or feature ofthe interbody spacer 910. Other connections can be used to detachablycouple the delivery instrument 920 to the interbody spacer 910. U.S.Pat. Nos. 8,632,594, 9,308,099, 10,105,238 and 10,201,431, which arehereby incorporated by reference, disclose delivery instruments,interbody spacers, connection features, and methods of operatingdelivery instruments and deploying interbody spacers. The deliveryinstrument 920 can be a delivery instrument and include featuresdisclosed in U.S. Pat. Nos. 8,632,594, 9,308,099, 10,105,238 and10,201,431. Other types of implantable devices and delivery instrumentscan be utilized. The configuration of the implant and correspondingdelivery instruments can be selected based on the procedure to beperformed.

FIG. 11 is a flow diagram illustrating a method for treating a subjectin accordance with an embodiment of the disclosure. In block 1002,incisions can be made in the subject's tissue to create first and secondportal sites (i.e., entrances). In some embodiments, the first andsecond entrances can be positioned on the same side of the subject'smidsagittal plane. In other embodiments, the first and second entrancescan be positioned on opposite sides of the subject's midsagittal plane.In yet other embodiments, the incisions can be made along the subject'smidsagittal plane.

Ports can be installed in each of the entrances. The sizes of the portscan be selected based on the size of the incision and characteristics ofthe tissue at the port site. For example, a tubular body of the port canbe sufficiently long to extend through the subject's skin, fascia, andmuscle. An access opening of the port can be sufficiently large to allowinstruments to be inserted into and through the ports, which can preventor inhibit tearing of tissue. Instruments can be delivered through theincisions into the patient without utilizing ports. Such instruments canhave relatively small diameters to limit or inhibit tearing of thetissue around the incision. In some procedures, ports can be installedin some incisions and instruments can be installed in other incisionswithout ports. A physician can determine whether to install ports basedon the instruments to be utilized and the position of the incisions.

In block 1004, a distraction instrument can be positioned at the firstportal site by inserting the distraction instrument through, forexample, an installed port. In some procedures, a cannula can bepositioned in the port and the distraction instrument can be deliveredthrough the lumen of the cannula. In other embodiments, the distractioninstrument can be inserted directly into the port without utilizing thecannula. Utilization of distraction instruments and cannulas arediscussed in connection with FIGS. 5-8 .

In block 1006, a visualization device can be positioned at a secondportal site by delivering the visualization device through a port. Thevisualization device can be installed with or without use of thecannula. Utilization of a cannula and a port are discussed in connectionwith FIGS. 1-7 . In some embodiments, the visualization device can be alow-profile fiber optic visualization system deliverable through aportal site in the form of a small incision. In these procedures, acannula may not be used since the visualization device has a smalldiameter. The visualization device can be kept at the same portal sitethroughout most of the surgical procedure period in which the spine isaltered. For example, the visualization device can be positioned at asingle portal site for at least 80% or 90% of the surgical period inwhich instruments are positioned in the subject. The visualizationdevice can be positioned within the subject such that an interbodyfusion device is capable of being implanted without removing theendoscope from the subject. This can reduce the overall surgery time.

A steerable visualization device can be used to facilitate navigationaround anatomical features. The steerable visualization device caninclude a fiberoptic scope, or a flexible or rigid instrument with oneor more illumination elements (e.g., fiber-optics for illumination) orimaging elements (e.g., charge-coupled devices for imaging) suitable forvisualizing the interior of otherwise inaccessible sites. In someembodiments, the visualization device can be rod-lens endoscopes with anouter diameter equal to or smaller than about 2 mm, 3 mm, 4 mm, 5 mm, 6mm, 8 mm, or 10 mm; and a length equal to or shorter than about 15 cm,20 cm, 30 cm, or 40 cm. The device can also have connectors (e.g.,electrical connectors, fluidic connectors, etc.), access ports (e.g.,access ports connected to lumens (e.g., lumens through which instrumentscan pass), or the like. In embodiments with an angled lens, thevisualization instrument can have approximately 15 degree, 30 degree, or45 degree lens angles, which are angled toward a light source. In otherangled lens embodiments, the visualization instrument can have anapproximately 15 degree, 30 degree, or 45 degree lens angled away from alight source. The angle of the lens can be selected based on the area tobe viewed. In some posterior or lateral spinal procedures, a 0 degreelens can provide a wide-angle view suitable for viewing nerve roots, thespinal cord, and intervertebral space. A 30 or 45 degree lens endoscopeangled toward the light source can be used to provide an angled viewtoward, for example, the midsagittal plane to view, for example, thespinous processes, spinal cord, central regions of the intervertebralspace, or the like. A 30 or 45 degree lens endoscope angled away fromthe light source can be used to provide an angled view toward thelateral features or the spine, such as nerve roots at the neuralforamen, side regions of the intervertebral space, or the like.

In some procedures, multiple visualization instruments are utilized. Inone procedure, multiple visualization instruments are positioned withinthe same port, which is large enough to allow relative movement betweenthe endoscopic instruments. In other procedures, endoscopic instrumentsare positioned in spaced apart ports. To provide bilateral viewing, afirst port and first endoscopic instrument can be positioned on one sideof the midsagittal plane of the subject, and the other port andendoscopic instrument can be positioned on the other side of themidsagittal plane. Multiple visualization instruments used in a singleprocedure can have different viewing characteristics.

The images of the subject's spine can be used to determine implantationinformation about the interbody fusion implant. Implantation informationcan include, without limitation, a recommended interbody fusion implant,expansion setting for the interbody fusion implant, and/or recommendedimplantation position for the interbody fusion implant. The user can bepresented information for viewing based on the analysis of the imagedata, including information for repositioning the interbody fusionimplant or information for collapsing the interbody fusion implant. Inblock 1008, tissue from the intervertebral space can be removed with atissue removal device positioned at the first entrance. In block 1010,adjacent vertebrae can be distracted using the distraction instrument toenlarge the intervertebral space between the adjacent vertebrae. Inblock 1012, an interbody spacer, such as an interbody fusion implant,can be delivered to the enlarged intervertebral space. The interbodyfusion implant can be delivered in a collapsed configuration through alumen of the distraction instrument. In block 1014, the interbody fusionimplant can be expanded laterally and vertically while a driverinstrument is positioned within the distraction instrument positioned atthe first entrance and while being endoscopically viewed in block 1016.The lateral and vertical expansion of the interbody fusion implant canbe sequential. For example, after the interbody fusion implant ishorizontally expanded, the interbody fusion implant can be verticallyexpanded to provide disc height restoration.

In block 1016, image data can be obtained by an endoscopic instrument.The image data can be video, still images, or other image data. Imagedata can be obtained before, during, and/or after expansion and analyzedwith endoscopic visualization to confirm the position of the expandedinterbody fusion implant to improve efficacy of surgeries by allowingthe physician to visually assess the procedure. For example, a firstimage of an implantation site can be obtained by the endoscopicinstrument. A second image of the implantation site can be obtainedusing the endoscopic instrument after delivery of the interbody fusionimplant. Image data can be analyzed to determine whether the expandedinterbody fusion implant is located at a deployment position based on aposition of the expanded interbody fusion implant shown in the secondimage.

In some embodiments, the first image and the second image can becompared to determine the position of the expanded interbody fusionimplant. If the interbody fusion implant is mispositioned, the user canbe notified of the mispositioning. The notification can be via anaudible alert, visual alert (e.g., an alert displayed on the display 162at FIG. 1 ), or by other suitable notification means. In block 1018, thedriver instrument can be separated from a locked expanded interbodyfusion implant, as discussed in connection with FIG. 10B. The implantedinterbody fusion implant can be visualized to confirm proper positioningand deployment of the implant. Visualization can be used if additionalprocedures are performed. Additional procedures may include, withoutlimitation, delivering bone, growth-promoting materials, or the like tothe intervertebral space. Visualization can also be used to view otherprocedures, such as fixation procedures involving pedicle screws,interspinous spacers, or the like.

The method of FIG. 11 can be performed using various systems disclosedherein. Additional instruments and steps can be performed as needed toprovide treatment flexibility. For example, decompression procedures canbe performed before or after distracting the adjacent vertebrae at block1010. Visualization can be used during the decompression procedure tovisually identify targeted tissue, as well as ensuring that non-targetedtissue (e.g., nerve tissue) is not traumatized. Although the method isdiscussed in connection with implanting an interbody fusion implant, themethod can be performed to deploy and implant other devices. Forexample, the method can be used to implant an articulatingintervertebral disc. Moreover, the multi-portal systems can be used toimplant rigid or fixed interbody fusion devices. The acts and steps inthe method of FIG. 11 can be modified based on the features of theimplant to perform, for example, an oblique lumbar interbody fusionprocedure, a lateral lumbar interbody fusion procedure, a posteriorlumbar interbody fusion procedure, a transforaminal lumbar interbodyfusion procedure, or an anterior lumbar interbody fusion procedure.

FIG. 12 illustrates a system 1110 for providing surgical assistanceaccording to an embodiment of the disclosure. The system 1110 canimprove surgeries by displaying image data, analyzing image data,suggesting steps in a surgical procedure, analyzing implants, or thelike. The system 1110 can comprise hardware components that improvesurgeries using, for example, a surgical assistance system 1164. Invarious implementations, the surgical assistance system 1164 can storepatient information, obtain image data, analyze information/data toobtain results, and use the results to provide feedback to a user. Thesurgical assistance system 1164 can analyze still images or video frominput devices 1120 to suggested implants for a procedure. For example,the surgical assistance system 1164 can recommend the number, size, andconfiguration of implants and surgical procedure. Based on therecommendations, the surgical assistance system 1164 can further suggestsurgical instruments, a surgical plan, and other information. Thesurgical plan can include (1) surgical steps, (2) number, size, and/orposition of ports, and/or (3) surgical approaches. For example, thesurgical assistance system 1164 can annotate an image (e.g., an X-rayimage, still image, video, etc.) with suggested insertion points alongthe subject's skin, surgical procedures (e.g., PLIF, ALIF, LLIF, etc.),access paths, etc. During a procedure, the surgical assistance system1164 can provide warnings or other feedback to surgeons.

System 1110 can include one or more input devices 1120 that provideinput to the processor(s) 1145 (e.g., CPU(s), GPU(s), HPU(s), etc.),notifying it of actions. The actions can be mediated by a hardwarecontroller that interprets the signals received from the input deviceand communicates the information to the processors 1145 using acommunication protocol. The processors 1145 can be used to analyze data,such as image data, to determine whether the expanded interbody fusionimplant is located at a deployment position based on a position of theexpanded interbody fusion implant shown in an acquired image.

Input devices 1120 can include, for example, visualization devices, suchas the visualization device 140 discussed in connection with FIGS. 1-6 ,endoscopic instruments, imaging devices (e.g., cameras), CRT machines,X-ray machines, or the like. The visualization, in some surgicalembodiments, enables surgeons to visually see and verify the vertebralbodies, vertebral spacing, damaged/displaced tissue, intervertebraldiscs (including bulging portions), presence of unwanted cartilage(e.g., cartilage buildup), bone, or tissue that is causing nerve rootcompression and damage to normal body functions. This information on theunwanted material can be documented and recorded by saving image datainto a computer database and printing color images (e.g., pictures)immediately for reference and recording. The physician can use theinformation to develop at least a portion of a surgical plan.

Additionally or alternatively, the input devices 1120 can include amouse, a keyboard, a touchscreen, an infrared sensor, a touchpad, awearable input device, a camera- or image-based input device, amicrophone, or other user input devices. For example, a mouse can beused to select or manipulate image data captured by visualizationdevices. A keyboard can be used to annotate image data. The number andconfiguration of the input devices can be selected based on thephysician.

Processors 1145 can be a single processing unit or multiple processingunits in a device or distributed across multiple devices. Processors1145 can be coupled to other hardware devices, for example, with the useof a bus, such as a PCI bus or SCSI bus. The processors 1145 cancommunicate with a hardware controller for devices, such as for adisplay 1130. The display 1130 can be used to display image data. Forexample, the display 1130 can correspond to the display 162 in FIG. 1 ,which can be connected to one or more visualization devices via a wiredor wireless connection (FIG. 1 shows a wired connection). The display1130 can present information for viewing by a user. The presentedinformation can include suggested implant information, suggestedsurgical instruments, information for implanting devices, informationfor repositioning the interbody fusion implant, information forcollapsing the interbody fusion implant, or the like. The informationcan be overlaid on or inserted into images or video. In someembodiments, the information can be annotations.

The display 1130 can provide graphical and textual visual feedback to auser. In some implementations, the display 1130 includes the inputdevice as part of the display, such as when the input device is atouchscreen or is equipped with an eye direction monitoring system. Insome implementations, the display is separate from the input device.Examples of display devices are: an LCD display screen, a light-emittingdiode (LED) display screen, a projected, holographic, or augmentedreality display (such as a heads-up display device or a head-mounteddevice), and so on. The display 1130 can provide high definitionvisualization.

Other I/O devices 1140 can also be coupled to the processor, such as anetwork card, video card, audio card, USB, firewire or other externaldevice, camera, printer, speakers, CD-ROM drive, DVD drive, disk drive,or Blu-Ray device. Other I/O devices 1140 can also include input portsfor information from directly connected medical equipment such as MRImachines, X-Ray machines, etc. Other I/O devices 1140 can furtherinclude input ports for receiving data from these types of machines fromother sources, such as across a network or from previously captureddata, for example, stored in a database.

The system 1110 can also include a communication device capable ofcommunicating wirelessly or wire-based with a network node. Thecommunication device can communicate with another device or a serverthrough a network using, for example, TCP/IP protocols. The system 1110can utilize the communication device to distribute operations acrossmultiple network devices.

The processors 1145 can have access to a memory 1150 in a device ordistributed across multiple devices. A memory includes one or more ofvarious hardware devices for volatile and non-volatile storage, and caninclude both read-only and writable memory. For example, a memory cancomprise random access memory (RAM), various caches, CPU registers,read-only memory (ROM), and writable non-volatile memory, such as flashmemory, hard drives, floppy disks, CDs, DVDs, magnetic storage devices,tape drives, device buffers, and so forth. A memory is not a propagatingsignal divorced from underlying hardware; a memory is thusnon-transitory. Memory 1150 can include program memory 1160 that storesprograms and software, such as an operating system 1162, surgicalassistance system 1164, and other application programs 1166. Memory 1150can also include data memory 1170 that can include, for example,implantation site information (e.g., level information, implantdeployment information, etc.), surgical plan data, user options orpreferences, image data, etc., which can be provided to the programmemory 1160 or any element of the system 1110.

Some implementations can be operational with numerous other computingsystems, environments, or configurations. Examples of computing systems,environments, and/or configurations that may be suitable for use withthe technology include, but are not limited to, personal computers,server computers, handheld or laptop devices, cellular telephones,wearable electronics, tablet devices, multiprocessor systems,microprocessor-based systems, programmable consumer electronics, networkPCs, minicomputers, mainframe computers, distributed computingenvironments that include any of the above systems or devices, or thelike.

The foregoing detailed description has set forth various embodiments ofthe devices and/or processes via the use of block diagrams, flowcharts,and/or examples. Insofar as such block diagrams, flowcharts, and/orexamples contain one or more functions and/or operations, it will beunderstood by those within the art that each function and/or operationwithin such block diagrams, flowcharts, or examples can be implemented,individually and/or collectively, by a wide range of hardware, software,firmware, or virtually any combination thereof. In one embodiment,several portions of the subject matter described herein may beimplemented via Application Specific Integrated Circuits (ASICs), FieldProgrammable Gate Arrays (FPGAs), digital signal processors (DSPs), orother integrated formats. However, those skilled in the art willrecognize that some aspects of the embodiments disclosed herein, inwhole or in part, can be equivalently implemented in integratedcircuits, as one or more computer programs running on one or morecomputers (e.g., as one or more programs running on one or more computersystems), as one or more programs running on one or more processors(e.g., as one or more programs running on one or more microprocessors),as firmware, or as virtually any combination thereof, and that designingthe circuitry and/or writing the code for the software and or firmwarewould be well within the skill of one skilled in the art in light ofthis disclosure. In addition, those skilled in the art will appreciatethat the mechanisms of the subject matter described herein are capableof being distributed as a program product in a variety of forms, andthat an illustrative embodiment of the subject matter described hereinapplies regardless of the particular type of signal-bearing medium usedto actually carry out the distribution. Examples of a signal-bearingmedium include, but are not limited to, the following: a recordable typemedium, such as a floppy disc, a hard disk drive, a CD, a DVD, a digitaltape, a computer memory, etc.; and a transmission type medium, such as adigital and/or an analog communication medium (e.g., a fiber opticcable, a waveguide, a wired communications link, a wirelesscommunication link, etc.).

C. Surgical Kits

FIG. 13 is a top plan view of a surgical kit 1200 that includescomponents discussed in connection with FIGS. 1-11, 14-16, and 18-19 .The kit 1200 can include cannulas 120, 150, and a set 1210 of ports. Aphysician can select appropriate ports based on locations of portalsites and instruments to be utilized. In the illustrative embodiment,the set 1210 includes four ports. A higher or lower number of ports canbe provided and can be of the same or different sizes. The kit 1200 caninclude a connector (e.g., a rigid connector) to couple togethercannulas (e.g., cannulas 120, 150, 1400). The cannulas can be coupledtogether before expanding the interbody fusion device at anintervertebral implantation site.

The kit 1200 can further include a plurality of decompressioninstruments. In the illustrated embodiment, the kit 1200 includes adebulking instrument 1220 and a reamer 1222. If the decompressioninstruments are utilized, a physician can select the port 1230 with alarge opening 1232. The kit 1200 can also include scalpels, dilators,rongeurs, irrigation cannulas, tissue-detecting or mapping cannulas,expanders, or other surgical instruments. For example, the kit 1200 caninclude the visualization device 140, the distraction instrument 510,the delivery or deployment instrument 920, and implantable devices 1238.The configuration and components for the kit can be selected based uponthe procedure to be performed. Example components for kits are discussedin connection with FIGS. 14-20 . A biportal kit with tissue-mappingcapabilities can have tissue-detecting cannulas, whereas biportal kitswith irrigation functionality can have cannulas with irrigationflowthrough cannulas. Biportal kits can have cannulas configured forboth tissue mapping and irrigation. Moreover, one or more of the kit'scomponents can be disposable and can be made, in whole or in part, frommetal, polymers, ceramics, composite materials, or other biocompatibleand sterilizable materials.

In some embodiments, the kit 1200 is a sterile universal biportal spinesurgery kit for performing different procedures. In some biportalprocedures, a first port and a second port can be selected from the set1210 based on the subject's anatomy and procedure to be performed. Thefirst and second ports can be inserted into incisions in the subject. Aninstrument cannula (e.g., cannula 120, cannula 150, cannula 1400) can beinserted into the first port. Another cannula can be inserted into thesecond port. Instruments (e.g., debulking instrument 1220, reamer 1222,etc.) positioned in the instrument cannula can be used to perform atleast a portion of the procedure while visualization is provided by animaging device positioned in the imaging cannula.

The surgical instruments can be selected based on the biportal spineprocedure to be performed. The instruments can be used to complete one,multiple, or all of steps of the biportal spine procedure with orwithout utilizing all of the surgical instruments in the kit. Universalspine surgical kits can also have instruments for interbody procedures,decompression procedures, fixation procedures, or combinations thereof.Instruments can be sequentially inserted in the instrument cannula toperform surgical steps. Each of the instruments can be configured to fitwithin the instrument cannula, thereby allowing the same cannula to beused for the entire procedure. In other procedures, multiple cannulascan be sequentially positioned within the same port. The port can reduceor eliminate tearing of tissue caused by insertion, removal, orpositioning of the cannulas.

In some embodiments, a surgery-specific kit 1200 can be configured toperform a particular type of procedure. A physician can select asurgery-specific kit 1200 based on the procedure to be performed.

In some procedures, the location of tissue can be mapped using one ormore energy-emitting elements coupled to the instrument cannula and/orthe imaging cannula. The energy-emitting elements can be tissue-mappingelements configured to identify tissue beneath the subject's skin.Mapping information can be used to position instruments, imagingdevices, cannulas, or the like. Advantageously, mapping can be performedwithout introducing additional instruments into the subject, therebyreducing procedure complexity, risk of complications, or the like. Thetissue of interest can be nerve tissue, connective tissue, anatomicalfeatures (e.g., nerve roots, nerve branches, etc.), or the like. Forexample, mapping can be used to identify the location of nerve rootsexiting the vertebral foramen, spinal ganglion, spinal nerves, or thelike.

The cannulas can be configured to be fluidically coupled to one or moreirrigation apparatuses. The fluidic coupling can be achieved using,without limitation, one or more fittings, connectors, hoses, conduits,or the like. An irrigation apparatus can include one or more fluidcontrol systems, pumps, vacuum or suction devices, conduits, sensors(e.g., flow sensors, fluid pressure sensors, blood sensors, etc.),controllers, or combinations thereof.

The kit 1200 can include one or more expanders that are part of orcouplable to a kit component. Expanders can be moved from an unexpandedconfiguration to an expanded configuration, thereby increasing a workingspace within the subject. The expander can be a mechanical expander, apneumatic expander, a self-expanding expander, or the like.

FIG. 14 is a perspective view of a cannula 1400 in accordance with anembodiment of the disclosure. The cannula 1400 can be used in a mannersimilar to the cannulas 120, 150, 810, 930 as discussed previously inconnection with FIGS. 1, 4-6, 10A, and 13. The cannula 1400 can includea distal end 1401, a proximal end 1402, and an elongated body 1404having a plurality of lumens extending from the distal end 1401 to theproximal end 1402. The lumens can be used to deliver instruments to asurgical site, deliver fluid into the subject, remove fluid from thesubject, or the like. This allows irrigation of the surgical site whileinstruments can access the site via a working lumen 1408. The workinglumen 1408 can be configured to receive a surgical instrument (e.g., adistraction instrument, decompression tool, etc.), a visualizationinstrument, an implantable device, or other instrument for use during asurgical procedure. The diameter of the working lumen 1408 can be equalto or smaller than about 2 mm, 3 mm, 4 mm, 5 mm, 6 mm, 8 mm, or 10 mm,and the outer diameter of the cannula 1400 can be equal to or smallerthan about 3 mm, 4 mm, 5 mm, 6 mm, 8 mm, 10 mm, or 12 mm. Other cannuladimensions can be selected based on the access path, instrumentdimensions, and procedure to be performed.

FIGS. 14A and 14B are perspective views of the distal end 1401 and theproximal end 1402, respectively, in accordance with an embodiment of thedisclosure. FIG. 14C is a longitudinal cross-sectional view as indicatedin FIG. 14A. Referring now to FIG. 14A, the distal end 1401 can includea first distal opening 1414, a second distal opening 1416, and a workinglumen opening 1418. The first and second openings 1414, 1416 can bepositioned on opposite sides of the working lumen opening 1418 and allowfluid flow therethrough. This allows fluid flows to be kept on oppositesides of the working lumen 1408. The configuration, number, andpositions of the openings for fluid flow can be selected based on thedesired flow of fluid. For example, the number of openings andcorresponding lumens can be increased to increase the flow rate ofirrigation fluid within the subject.

Referring now to FIG. 14B, the proximal end 1402 can include a firstproximal opening 1446 and a second proximal opening 1448. As shown inFIG. 14C, a first fluid lumen 1441 extends between the distal opening1414 and a proximal opening 1446, and a second fluid lumen 1412 extendsbetween the distal opening 1416 and the proximal opening 1448. Thediameter and configurations of the lumens can be selected based on theprocedure to be performed. The configurations of the lumens 1408, 1410,1412 can be, for example, circular, elliptical, or polygonal (includingrounded polygonal). In addition, the cross-sectional shapes of lumenscan vary along the length of lumens, for example, when a circular lumenterminates at a rectangular aperture at the distal end 1401 of thecannula 1400.

Referring to FIG. 14C, the working lumen 1408 can be substantiallycentered within the elongate body 1404 so that its distal opening 1409is correspondingly centered at the face of the distal end 1401, or itcan be offset toward the side of the body 1404 depending on itsconfiguration. Similarly, the fluid lumens 1410, 1412 can be positionedwithin the cannula body 1404 such that their distal apertures 1414, 1416are located at other positions than those illustrated. For example, thelumens 1410, 1412 could be located adjacent to one another on the sameside of the cannula body 1404 to aid in coupling the proximal aperturesto a fluid control system. Additionally, according to a variety ofembodiments, any of the openings 1406, 1414, 1416, 1446, 1448 can belocated along an outer surface 1413 of the cannula body 1404.

With continued reference to FIG. 14C, the fluid lumens 1410, 1412 can beconfigured to allow surgical irrigation fluid to flow through in eitherdirection according to some embodiments. For example, the first fluidlumen 1410 can be configured to allow a flow of irrigation fluid from asupply connected to the proximal end 1402 to the distal end 1401, whilethe second fluid lumen 1412 can be configured to allow a flow ofirrigation fluid from the distal end 1401 to the proximal end 1402. Invarious arrangements, both lumens 1410, 1412 can be used to flow fluidin the same direction; only one lumen can be configured to flow fluid,while the other lumen is closed, capped, obturated, or otherwise notused to flow fluid; or neither lumen can be configured to flow fluid andboth can be closed, capped, obturated, or otherwise not used to flowfluid.

The cannula 1400 can have one or more tissue-mapping probes. Withreference again to FIG. 14A, tissue-mapping probes 1420 can beconfigured to output energy (e.g., electrical energy, radio frequencyenergy, electromagnetic energy, ultrasound energy, acoustic energy,etc.) useful for identifying the locations of tissue at a treatmentsite. The interaction of the energy with various tissue can provide aresponse that can be measured using a variety of techniques. Forexample, the tissue-mapping probes 1420 can be neuromonitoringelectrodes used with electromyography (EMG) techniques. For example,electrical signals emitted by the electrodes 1420 can depolarize nearbynerves, causing a response in an innervated muscle detectable with anEMG system. Other techniques include, but are not limited to,ultrasonography, fluoroscopy, doppler imaging, and optical imaging. Theconfiguration of the tissue-mapping probes 1420 can be suitable forlocating a variety of tissues, including nerve tissue, dura, bonetissue, ligaments, ligamentum flavum, and bone graft material, as wellas areas of interest, such as tissue margins, tissue interfaces, or thelike.

The arrangement of the tissue-mapping probes 1420 can be selected to aidthe tissue-mapping technique. For example, the spaced-apart probes 1420arranged as illustrated in FIG. 14A can provide directional information.Tissue of interest can respond more strongly to energy output from aprobe in closer proximity than from the other probes positioned furtheraway on the cannula. The tissue-mapping probes 1420 can also beconfigured to emit energy sequentially or in another suitable pattern,such that tissue in each direction associated with a particulartissue-mapping probe can be probed in the same sequence or pattern. Thisallows tissue-mapping to be performed without adjusting the positions ofthe tissue-mapping probes 1420. For example, if the distal end 1401 ofthe cannula 1400 is positioned over a nerve root, the tissue-mappingprobes 1420 can be used to detect the presence of a nerve root andadditional information, such as the size of a nerve root, orientation ofthe nerve root, depth of the nerve root, or the like. Advantageously,the mapping can be performed without physically contacting and injuringthe nerve tissue. Nerve mapping can be performed to locate spinal nervesaround and adjacent to the spinal column.

Referring to FIGS. 14A and 14C, a transmission line 1430 coupled to thetissue-mapping probes 1420 can extend from the distal end 1401 to theproximal end 1402. The transmission line 1430 can include, withoutlimitation, one or more wires, fiber optics, etc., and can be locatedwithin a sidewall of the body 1404. The transmission line 1430 can beconfigured to transmit energy, electrical signals, and/or opticalsignals, including digital and analog signals of various types. In someembodiments, the transmission line 1430 can be configured to transmitboth energy to one tissue-mapping probe and signals received fromanother tissue-mapping probe. Referring now to FIGS. 14B and 14C, thetransmission line 1430 can connect to an interface 1440 at the proximalend 1402. The interface 1440 can include, without limitation, one ormore plugs, connectors, or other components that provides a connectionpoint to a tissue-mapping system.

FIG. 15 is a front elevation view of a cannula 1500. The description ofthe cannula 1400 of FIGS. 14-14C applies equally to the cannula 1500unless indicated otherwise. The cannula 1500 can have a tissue-mappingarray 1520 with tissue-mapping probes arranged circumferentially arounda distal face 1502 of a distal end 1501. The increased number oftissue-mapping probes of FIG. 15 can provide increased directionalresolution for tissue-mapping. Additionally, different probes can beconfigured to emit different types of energy. Other probes can also beconfigured to receive a return signal.

The tissue-mapping array 1520 can include neuromonitoring electrodes1522, ultrasonic transducers 1524, and photoacoustic sensors 1526. Thearrangement of multiple modalities of tissue-mapping can improve tissuelocation and visualization. Neuromonitoring electrodes 1522 can aid thepositioning of the cannula so as to avoid nerve contact duringinsertion, while ultrasonic emitters and photoacoustic sensors canprovide information related to the location of various tissues andtissue interfaces. The number (e.g., five, six, eight, ten, etc.),positions, and configuration of the tissue-mapping probes can beselected based on the mapping to be performed. For example, the numberof electrodes can be increased to provide higher-resolution mapping. Insome embodiments, some probes can be arrayed around the side of thedistal end, while others are arrayed on the distal face 1502. The probescan be flush with the outer surface 1503 of the cannula body or slightlyrecessed within the cannula body. In other embodiments, a probe canextend past the surface 1503.

FIG. 16 is a side view of a cannula including a tissue-mapping probe1620 according to a particular embodiment of the disclosure. Thedescription of the cannula 1400 of FIGS. 14-14C and cannula 1500 of FIG.15 applies equally to the cannula 1600 unless indicated otherwise. Thetissue-mapping probe 1620 extends distally from the distal end 1631 ofthe cannula body 1604. The distance d of the tissue-mapping probe 1620extends from the body 1640 can be selected based on the desiredclearance for the lumen opening 1622 of the working lumen 1624 (shown indashed line). Such probe protrusion can aid in techniques like EMGduring the guided insertion of a cannula, where the probe leads the bodyof the cannula and can determine tissue location before the tissue iscontacted by the cannula. In some embodiments, the distal end 1631 canhave a distal face 1632 that is generally angled with respect to alongitudinal axis 1636 of the cannula 1600. For example, the illustratedface 1632 can be non-orthogonal with respect to the longitudinal axis1636 to provide lateral clearance to instruments. When the probe 1620 isadjacent or contacting tissue 1640 (illustrated in dashed line),instruments can be easily passed out to the working lumen in a lateraldirection, as indicated by the arrow 1644. Advantageously, the probe1620 can physically contact the tissue to help maintain spacing betweenthe tissue 1640 and the working instrument. The configuration andposition of the probe 1620 can be selected based on the desired mappingand tissue interaction. For example, the probe 1620 can have a blunt orrounded tip 1641 configured to slide atraumatically across tissue. Inother embodiments, the tip 1641 can be pointed or relatively sharp topierce tissue. In some procedures, the piercing probe 1620 can beinserted into tissue to map tissue underlying the exposed tissuesurface.

FIG. 17 is a detailed side view of cannulas 1720, 1721 positioned toperform a procedure in accordance with embodiments of the disclosure.Cannulas 1720, 1721 can be positioned in respective ports 472, 474 andextend through the subject's skin 460 and through subcutaneous tissue462. The cannulas 1720, 1721 can be inserted through the respectiveports 472, 474 such that their distal ends are adjacent to or at atreatment site 1750 (generally identified in dashed line). The insertioncan be guided by a tissue-mapping probe 1724 that is operably coupled toa tissue-mapping system 1740 via a transmission line 1744. The cannula1720 can have the features of the cannula 1600 discussed in connectionwith FIG. 16 .

The cannulas 1720, 1721 have fluid lumens 1725, 1726, respectively,configured to circulate surgical irrigation fluid through the treatmentsite 1750. The fluid lumen 1726 can be fluidically connected to a fluidsupply system 1760. The fluid lumen 1725 can be fluidically connected toa fluid return system 1770 at the proximal end of the cannula 1720. Insome embodiments, the fluid supply system 1760 and fluid return system1770 are elements of an integrated fluid control system. The systems1760, 1770 can include components and features discussed in connectionwith system 1110.

The circulating fluid flow can be controlled and monitored by the fluidsupply system 1760 and/or the fluid return system 1770. The flow can bepresent while an instrument assembly 130 and visualization instrument140 are positioned within the working lumens 1706, 1708 of the cannulas1720, 1722, respectively. The irrigation fluid can improve visibility atthe treatment site 1750 and provide improved control of fluid pressureand flow rate during a procedure. In various embodiments, the cannulas1720, 1722 can be configured as described with regard to cannulas 1400,1500, and 1600 discussed above in connection with FIGS. 14A-C, 15, and16, and as described below with regard to cannula 1800.

The tissue-mapping probe 1724 can be used to map tissue near thetreatment site 1750 while the instrument assembly 130 and visualizationinstrument 140 are positioned within the cannulas 1720, 1722,respectively. In this way, according to some embodiments, a physiciancan receive periodic or continual updates regarding the position oftissue near or at the treatment site 1750 as the surgical procedureprogresses. The tissue-mapping system 1740 can be an element of thesystem 1110 for providing surgical assistance as discussed above inconnection with FIG. 12 . The tissue-mapping system 1740 can include,without limitation, one or more displays, computers, computing devices,processors, displays, or combinations thereof. Information relating tothe location of tissue (e.g., tissue location information determined byenergy output by tissue-mapping probe 1724), and/or information relatingto the visualization of the treatment site 1750 (e.g., visualizationinformation obtained via the visualization instrument 140) can beprocessed and combined and presented to the physician to improvesurgeries. In some embodiments, the tissue-mapping system 1740 canprovide a visualization of tissue locations at the treatment site 1750and overlay this visualization onto image data (e.g., still images,video, etc.) obtained from the visualization instrument. The procedureof FIG. 17 can employ other cannulas, ports, or components discussedherein.

FIG. 18 is a side view of a cannula 1800 according to embodiments of thedisclosure. FIG. 19 is a top view of the cannula 1800 with the cannulabody 1801 shown in dashed line. The cannula 1800 can include an expanderor spacer 1810 (“expander 1810”) coupled to a distal end 1803 of anelongate body 1801 of the cannula 1800. The expander 1810 can have astowed configuration (as illustrated in FIG. 18 ) and a deployedconfiguration (as illustrated in FIG. 19 ). The expander 1810 can betranslated relative to the distal end 1803 (FIG. 18 ) via a movablecoupler 1811. The movable coupler 1811 can be moved away from the distalend 1803, as indicated by arrow 1813 of FIG. 18 . In some procedures,the coupler 1811 is slidably disposed within a side wall of the elongatebody 1801 such that a physician can manually push the expander 1810distally. In other embodiments, the coupler 1811 is fixedly coupled toelongate body 1801. For example, the coupler 1811 can be a rodintegrally formed with or coupled to the elongate body 1801. In furtherembodiments, the coupler 1811 can be rotatably coupled to the distal end1803. This allows the spacer 1810 to be rotated relative to elongatebody 1801. For example, the expander 1810 can be rotated about alongitudinal axis 1811 of the coupler 1811. The configuration of thecoupling arrangement can be selected based on the desired movability ofthe expander 1810.

The expander 1810 can have an articulatable body movable between aring-shaped or spiral configuration and expanded configuration. FIG. 18shows the expander 1810 in a spiral configuration. Articulated segmentscan be connected via joints or pivots to move toward the expandedconfiguration of FIG. 19 . The segmented sections of the body of theexpander 1810 can be connected by joints 1823 (one identified in FIG. 19) that can include, without limitation, one or more hinges, joints,living hinges, or the like. The expander 1810 can include tissue-mappingelements, contact sensors, anchors, or other features for engaging orcontacting tissue. In some embodiments, the expander 1810 can includeone or more deployable arms or tines to allow further expansion of thespacer 1810. When deployed, the expander can create a working volume ata treatment site within a subject.

In other embodiments, the expander can be an expandable cone, funnel, orother suitable shape to provide increased working volume near or at atreatment site. The expander allows visualization of the volumepartially bounded by the expander when in the deployed configuration.For example, a visualization instrument positioned within a secondcannula near to the cannula 1800 can visualize the region interior tothe spacer by viewing through an unenclosed side of the expander 1810.In some embodiments, the expander 1810 can have an aperture, a window,or other opening to permit visualization of the partially boundedregion.

The expander 1810 can have tissue-mapping probes 1824 positioned at theexterior surface of the segments. The tissue-mapping probes 1824 can beconfigured to output energy similarly to the tissue-mapping probes 1420,1520, 1620 discussed above in connection with FIGS. 14A-16 . Thetissue-mapping probes 1824 can be in addition to tissue-mapping probe1822 (FIG. 18 ) positioned at the distal end of the cannula 1800. Thetissue-mapping probes 1824 can aid in the deployment of the expander1810, help locate and orient the expander 1810, and provide feedback toavoid contacting nerve tissue or other tissue.

FIG. 20 is a flow diagram illustrating a method 2000 for treating asubject in accordance with an embodiment of the disclosure. At block2002, a subject's tissue is incised and incisions at locations in theincisions. Block 2002 can be similar to block 1002 described above inconnection with FIG. 11 . At block 2004, a first cannula can bepositioned in a port at a first location in the subject's tissue. Aninstrument, for example, a distraction instrument, can be insertedthrough the working lumen of the cannula. Utilization of distractioninstruments and cannulas are discussed in connection with FIGS. 5-8 .Various additional embodiments of cannulas are discussed in connectionwith FIGS. 14A-16 and 18-19 .

At block 2006, a visualization device can be inserted through a secondcannula positioned at a second portal site. Utilization of avisualization device at a second portal site is discussed above inconnection with FIG. 11 , for embodiments where a visualization devicemay be used with a second cannula at a second portal site.

In optional block 2008, a spacer can be deployed at a treatment site.The expander can enlarge a working volume at the treatment site toimprove irrigation fluid flow, improve visualization, and/or aid intissue-mapping. For example, the expander can increase visibility and/oraccess to the surgical location and can be configured to maintain anexpanded configuration. The expander can be engageable and disengageablewith the cannula body. Deploying an expander is discussed above inconnection with FIGS. 18 and 19 .

At block 2010, tissue-mapping probes on the first and/or second cannulascan be used to determine the locations of tissue at or near a treatmentsite within the subject. Tissue-mapping probes and tissue-mappingsystems are discussed above in connection with FIGS. 14A-19 . In someembodiments, the tissue-mapping system can provide information inaddition to image data provided by an endoscopic instrument. Theinformation can be combined with the visualization image data to providean image overlay or other indication of the location of tissue withinthe subject. The tissue-mapping information can be used if additionalprocedures are performed.

In block 2012, irrigation fluid can be circulated through a treatmentsite via the first and second cannulas. The fluid lumen of the firstcannula can be fluidically connected to a fluid supply system to supplyfluid at a controlled pressure or flow rate. The fluid lumen of thesecond cannula can be fluidically connected to a fluid return system toreturn fluid from the treatment site. The deployed expander can aid incontrolling the fluid flow by providing a controlled boundary for theworking volume at the treatment site. According to several embodiments,the first and second cannulas can have additional fluid lumens that canbe connected to a fluid control system. The fluid control system canthen be used to configure a fluid lumen to supply or return irrigationfluid. Thus, a first cannula can have, for example, both a fluid lumenconfigured to supply irrigation fluid and a fluid lumen configured toreturn irrigation fluid, while a second cannula has a fluid lumenconfigured to return irrigation fluid and a fluid lumen configured toneither supply nor return irrigation fluid.

At procedure 2013, blocks 2014-2020 describe various steps, includingremoving tissue from a treatment site, moving an interbody fusionimplant to an implant site, expanding the implant, and visualizing theexpansion. These steps are similar to steps at blocks 1008-1016discussed above in connection with FIG. 11 . Steps can be removed andperformed in different orders.

The components discussed herein can be mixed and matched to providedesired functionality. For example, the cannulas and instrumentsdiscussed in connection with FIGS. 1 and 13 can include tissueexpanders, tissue-mapping elements, visualization devices, or otherfeatures to provide desired functionality. The components can beintegrated into instruments and cannulas or can be separate components.For example, the expander 1810 discussed in connection with FIGS. 18 and19 can be coupled to other cannulas discussed herein using a clamp, pinconnectors, or other suitable connection arrangement. This allows theexpander 1810 to be coupled to a wide variety of different types ofcannulas. Additionally, distal regions of instruments, cannulas, andexpanders can have atraumatic designs to reduce or limit tissue injury.By way of example, the expander 1810 of FIGS. 18 and 19 can have roundeddistal regions to help slide along tissue, thereby limiting orpreventing tissue injury. In other embodiments, expanders and cannulascan have relatively sharp edges to facilitate cutting, abrading, orotherwise manipulating tissue. A kit can have both atraumatic andnon-atraumatic instruments to allow a user to select how tissue may ormay not be affected by the instruments and cannulas. Although lumens arewithin cannulas, a separate tube can be couplable to cannulas. Forexample, a bone dust removal tube can include a connector or clamp fordetachably coupling to cannulas.

The above detailed descriptions of embodiments of the technology are notintended to be exhaustive or to limit the technology to the precise formdisclosed above. Although specific embodiments of, and examples for, thetechnology are described above for illustrative purposes, variousequivalent modifications are possible within the scope of thetechnology, as those skilled in the relevant art will recognize. Forexample, while steps are presented in a given order, alternativeembodiments may perform steps in a different order. Features fromvarious systems, methods, and instruments can be combined with featuresdisclosed in U.S. Pat. Nos. 8,632,594, 9,308,099, 10,105,238 and10,201,431, which are hereby incorporated by reference and made a partof this application. Variations of the implants are contemplated. Forexample, the interbody spacer 910 (FIGS. 9A-9C) may be provided withdifferent overall heights covering a range of intervertebral discheights. In other examples, the interbody spacer 910 may be providedwith different lordotic and/or kyphotic angles. In still other examples,the interbody spacer 910 may be provided with other patterns orfeatures, such as spikes, protrusions, or the like, on the bonecontacting surfaces that provide stability and/or resistance to shiftingpositions. The implant may be made from metal, polymers, ceramic,composite, or other biocompatible and sterilizable material. Differentmaterials may be combined in what is described herein as a single part.A surgical kit can include components discussed in connection with, forexample, FIGS. 1-11, 14-16, and 18-19 . The kit can include cannulas,ports, fluid components, tissue-mapping elements, expanders,combinations thereof, or the like.

Systems, components, and instruments disclosed herein can be disposableor reusable. For example, the ports, instruments, or cannulas can bedisposable to prevent cross-contamination. As used herein, the term“disposable” when applied to a system or component (or combination ofcomponents), such as an instrument, a tool, or a distal tip or a head,is a broad term and generally means, without limitation, that the systemor component in question is used a finite number of times and is thendiscarded. Some disposable components are used only once and are thendiscarded. In other embodiments, the components and instruments arenon-disposable and can be used any number of times. In some kits, all ofthe components can be disposable to prevent cross-contamination. In someother kits, components (e.g., all or some of the components) can bereusable.

Where the context permits, singular or plural terms may also include theplural or singular term, respectively. Moreover, unless the word ‘or’ isexpressly limited to mean only a single item exclusive from the otheritems in reference to a list of two or more items, then the use of “or”in such a list is to be interpreted as including (a) any single item inthe list, (b) all of the items in the list, or (c) any combination ofthe items in the list. Additionally, the term “comprising” is usedthroughout to mean including at least the recited feature(s) such thatany greater number of the same feature and/or additional types of otherfeatures are not precluded. It will also be appreciated that specificembodiments have been described herein for purposes of illustration, butthat various modifications may be made without deviating from thetechnology. Further, while advantages associated with certainembodiments of the technology have been described in the context ofthose embodiments, other embodiments may also exhibit such advantages,and not all embodiments need necessarily exhibit such advantages to fallwithin the scope of the present technology. Accordingly, the disclosureand associated technology can encompass other embodiments not expresslyshown or described herein.

What is claimed is:
 1. A cannula comprising: an elongate body includinga proximal end and a distal end; a plurality of lumens extending fromthe proximal end to the distal end of the elongate body, wherein theplurality of lumens includes a first fluid lumen configured to provideflow of fluid therethrough and a working lumen configured for allowing asurgical instrument to pass therethrough; and a plurality oftissue-mapping probes disposed at the distal end of the elongate bodyand spaced circumferentially around the working lumen, wherein thetissue-mapping probes each include an electrode configured to emitenergy to detect tissue such that the plurality of tissue-mapping probesacquire additional information of the detected tissue.
 2. The cannula ofclaim 1, further comprising at least one transmission line within theelongate body and electrically coupled to the plurality oftissue-mapping probes, and wherein the plurality of tissue-mappingprobes are configured to emit the energy for identifying nerve tissuewhile the surgical instrument is positioned in the working lumen.
 3. Thecannula of claim 1, wherein the plurality of lumens further includes asecond fluid lumen configured to provide flow of fluid therethrough. 4.The cannula of claim 3, wherein: the first fluid lumen is configured toprovide flow of irrigation fluid from the proximal end to the distal endand into a surgical site; and the second fluid lumen is configured toprovide flow of irrigation fluid from the surgical site through thedistal end and to the proximal end.
 5. The cannula of claim 4, whereinthe proximal end of the cannula is configured to be coupled to asurgical irrigation supply system to fluidically couple one or both ofthe first fluid lumen and the second fluid lumen to the surgicalirrigation supply system.
 6. The cannula of claim 1, wherein theplurality of tissue-mapping probes include neuromonitoring electrodes.7. The cannula of claim 1, wherein the plurality of tissue-mappingprobes are operably coupled to at least one transmission line extendingalong the elongate body.
 8. The cannula of claim 7, wherein the at leastone transmission line is operably connectable to a tissue-mapping systemprogrammed to identify tissue based, at least in part, on output fromthe plurality of tissue-mapping probes.
 9. The cannula of claim 8,wherein the at least one transmission line is configured to transmit oneor both of electrical signals and optical signals.
 10. The cannula ofclaim 1 wherein the additional information includes at least one of anerve root size, a nerve root orientation, or a nerve root depth.
 11. Akit for multi-portal spine surgery techniques, the kit comprising: aplurality of cannulas each including a working lumen, a first fluidlumen, a second fluid lumen, and at least one probe, wherein at leastone of the plurality of cannulas includes a plurality of tissue-mappingprobes disposed at the distal end thereof and spaced circumferentiallyaround the working lumen, wherein the tissue-mapping probes each includean electrode configured to emit energy to detect tissue such that theplurality of tissue-mapping probes acquire additional information of thedetected tissue; and a plurality of surgical ports each sized to receiveat least one of the plurality of cannulas therethrough.
 12. The kit ofclaim 11, wherein the surgical ports are configured to extend through asubject's skin and fascia.
 13. The kit of claim 11, wherein the kit is asterile universal spine surgery kit.
 14. The kit of claim 11, furthercomprising: at least one surgical instrument; and packaging holding theplurality of cannulas, the plurality of ports, and at least one surgicalinstrument.
 15. The kit of claim 14, wherein the at least one surgicalinstrument includes one or more of a distraction instrument, a deliveryinstrument, a scalpel, a dilator, a rongeur, a debulking instrument, anda reamer.
 16. The kit of claim 11, further comprising at least oneimplantable device.
 17. The kit of claim 11, further comprising avisualization instrument.